- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $1,548.82
| Professional | | $645.65 | $912.01 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,621.81 / $2,884.03
| Professional | | $1,047.13 | $1,621.81 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,344.23 / $3,630.78
| Professional | | $1,348.96 | $2,344.23 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $3,311.31
| Professional | | $1,348.96 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,995.26 / $6,606.93
| Professional | | $1,000.00 | $1,995.26 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $3,235.94
| Professional | | $891.25 | $1,548.82 | $3,235.94 |